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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 9 /- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 2-_.I�-/7 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Jo4quin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ,9 C <br /> CENSUS TRACT <br /> Owner's Name i� it rvr� Phone t- -' g.Z�� <br /> Address `J7 � City <br /> Contractor's Name � ,�C //1�2� License4�`2—hone -S/ <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION / / DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENTFIV <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC,WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation _ <br /> t/ Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing �+ <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump .-. H.P. J E <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting thewell in use. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU NG AND A FINAL INSPECT ON. <br /> SIGNED TITLE <br /> DRAW P OT PLAN ON REVERSE SIDE) j <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I -7 <br /> APPLICATION ACCEPTED BY DATE / —47-77 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II /FINAL INSPECTION <br />'INSPECTION BY DATE _ ,9' INSPECTION BY DATE <br /> E H 1426 Rev- .1-74 <br /> UP . 2M <br />